Breast and the Axilla

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The anatomy and physiology of human breast.

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Breast and the Axilla

  1. 1. THE BREAST AND THE AXILLA
  2. 2. <ul><li>ALL </li></ul><ul><li>IMAGES, PICTURES </li></ul><ul><li>AND </li></ul><ul><li>CLIPS </li></ul><ul><li>ARE TAKEN FROM VALID RESOURCES FOR </li></ul>EDUCATIONAL PURPOSES
  3. 3. CONTENTS <ul><li>ANATOMY AND PHYSIOLOGY </li></ul><ul><li>PATHOPHYSIOLOGIC STATES AND OTHER FINDINGS </li></ul>III. ASSESSMENT <ul><li>DOCUMENTATION </li></ul>I. ANATOMY AND PHYSIOLOGY A. BREAST a. Location b. Structures c. Size, Shape and Appearance d. Development B. AXILLA, LYMPHATICS and BLOOD SUPPLY a. Blood Supply b. Lymph System <ul><li>HEALTH HISTORY </li></ul>II. HEALTH HISTORY A. Ask about reason for seeking care. B. Ask about personal and family medical history C. Ask about her current health <ul><li>III. ASSESSMENT </li></ul><ul><li>A. BREAST </li></ul><ul><li>INSPECT </li></ul><ul><li>PALPATE </li></ul><ul><li>B. AXILLAE </li></ul><ul><li>INSPECT </li></ul><ul><li>PALPATE </li></ul><ul><li>PATHOPHYSIOLOGIC STATES </li></ul><ul><li>a. Breast Nodule </li></ul><ul><li>b. Breast Dimpling </li></ul><ul><li>c. Peau d’orange </li></ul><ul><li>d. Nipple Retraction </li></ul><ul><li>e. Nipple Discharge </li></ul><ul><li> f. Pain </li></ul><ul><li>g. Visible Veins </li></ul><ul><li>h. Mastitis </li></ul><ul><li>DOCUMENTATION </li></ul>
  4. 4. A N A T O M Y B R E A S T OF THE
  5. 5. BREAST AND AXILLA <ul><li>I. ANATOMY AND PHYSIOLOGY </li></ul><ul><li>A. BREAST </li></ul><ul><li>a. * Location </li></ul><ul><ul><ul><li>Anterior chest wall </li></ul></ul></ul><ul><ul><ul><li>Between 2nd / 3rd and the 6th / 7th ribs </li></ul></ul></ul><ul><ul><ul><li>Over the pectoralis major muscle </li></ul></ul></ul><ul><ul><ul><li>Between the sternal border and the midaxillary line </li></ul></ul></ul><ul><ul><ul><li>Superior lateral quadrant of breast extends diagonally upwards towards the axillae known as the tail of Spence. </li></ul></ul></ul>I. ANATOMY AND PHYSIOLOGY / BREAST / Location
  6. 6. <ul><ul><li>b Structures </li></ul></ul>I. ANATOMY AND PHYSIOLOGY / BREAST / Structures <ul><ul><li>- pigmented erectile tissue located in the center of each breast </li></ul></ul><ul><ul><li>Areola </li></ul></ul><ul><ul><li>Nipple </li></ul></ul><ul><ul><li>– pink / brown pigmented region surrounding the nipple </li></ul></ul>
  7. 7. I. ANATOMY AND PHYSIOLOGY / BREAST / Structures <ul><ul><ul><li>Glandular lobes – contains the alveoli that produce milk </li></ul></ul></ul><ul><ul><ul><li>Adipose tissue – surrounds glands and extends throughout the breast, gives the breast its size, shape and a soft consistency </li></ul></ul></ul><ul><ul><ul><li>Lactiferous ducts * – transport milk from each lobe to the nipple </li></ul></ul></ul><ul><ul><ul><li>Cooper’s ligaments * – fibrous bands attached to the chest wall musculature that support each breast </li></ul></ul></ul><ul><ul><ul><li>Connective tissues - collagen and elastin, gives breast its characteristic bounce </li></ul></ul></ul>
  8. 8. I. ANATOMY AND PHYSIOLOGY / BREAST / Structures ! The male breast resembles the rudimentary female breast and has no lobules or alveoli .
  9. 9. <ul><li>c. Shape, Size & Appearance </li></ul><ul><ul><ul><ul><ul><li>Depends on the support </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Internal Support: Cooper’s ligaments, and the underlying chest on which they rest </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>External Support: Skin covering </li></ul></ul></ul></ul></ul>I. ANATOMY AND PHYSIOLOGY / BREAST / Shape, Size and Appearance
  10. 10. <ul><ul><ul><ul><ul><li>c. Shape, Size & Appearance </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Factors that may influence a woman’s breast size include: </li></ul></ul></ul><ul><li>Volume of breast tissue </li></ul><ul><li>Thickness and elasticity of the breast skin </li></ul><ul><li>Family history </li></ul><ul><li>Age </li></ul><ul><li>Weight loss or gain </li></ul><ul><li>Degree of hormonal influences on the breast such as estrogen and progesterone during pregnancies and lactation, and menopause </li></ul>I. ANATOMY AND PHYSIOLOGY / BREAST / Shape, Size and Appearance It is typical for a woman's breasts to be unequal in size particularly while the breasts are developing. Statistically it is slightly more common for the left breast to be larger. !
  11. 11. <ul><li>d. Development </li></ul>I. ANATOMY AND PHYSIOLOGY / BREAST / Development Before puberty Early puberty Late puberty - Adulthood the breast is flat except for the nipple that sticks out from the chest the areola becomes a prominent bud; breasts begin to fill out glandular tissue and fat increase and becomes elastic, areola becomes flat During pregnancy After pregnancy After menopause the breast increase in size, areola darkens, nipples become larger and more erect, blood vessels within the breast enlarge revert to previous size with some sagging and stretch marks (p19) decreased estrogen levels cause atrophy of breast tissue and fatty replacements, flabbier, nipples flatten, ducts feels like firm strings (p22)
  12. 12. Human breast tissue begins to develop in the sixth week of fetal life. I. ANATOMY AND PHYSIOLOGY / BREAST / Development (Uterine development)
  13. 13. Breast tissue * initially develops along the lines of the armpits and extends to the groin (called the milk ridge) . I. ANATOMY AND PHYSIOLOGY / BREAST / Development (milk ridge & supernumerary nipples)
  14. 14. I. ANATOMY AND PHYSIOLOGY / BREAST / Development (milk ridge & supernumerary nipples) Supernumerary nipples develop along the mammary line. !
  15. 15. Anne Boleyn Second wife to Henry VIII of England, and mother of Elizabeth I, is said have had a third nipple or even a third breast. This may well have been a slanderous rumour, as in Tudor times these &quot;malformations&quot; were considered to be a sign of the person having been a witch. The circumstances of her marriage to the king, who had divorced his first wife, made her a controversial figure. Carrie Underwood During her American Idol audition admitted to have had a third nipple which looked like a mole Famous personalities or characters known to have Extra or Supernumerary nipples are….
  16. 16. Krusty the Klown In an episode of The Simpsons, Bart, among other things knows Krusty the Klown has a third nipple, to see if he isn't an imposter.
  17. 17. I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Stage Tanner’s Stage expounds the 1 st 3 columns on Breast Development found in page 11 Tanner's stages are based on studies of white English girls. An American survey found that black girls tended to advance more quickly. Genital and pubic hair development is also classified by Tanner. Tanner's stages The preadolescent breast (Stage 1 per Tanner's sex maturity ratings) consists of a small elevated nipple with no significant underlying breast tissue. Puberty begins (usually between ages of 8 and 13, average age is 11) with the development of breast tissue and pubic hair. With the hormonal changes of puberty, breast buds form. This second stage of breast development is the breast bud stage. Here, there is elevation of the breast and nipple as a small mound; the areola begins to enlarge. Milk ducts inside the breast begin to grow. In Stage 3, there is further enlargement and elevation of the breast and areola (with no separation of their contours) The areola begins to darken in color. The milk ducts give rise to milk glands that also begin to grow. Next, there is projection of the areola and nipple to form a secondary mound (stage 4). In the mature adult breast (stage 5), there is projection of the nipple only (though in some woman the areola continues to form a secondary mound .
  18. 18. Edward Tanner also developed different Bra Classifications based on his Stages of Breast Development I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Bra Classificaion Breast and bra classification is as follows (from smallest to largest): A, B, C, D, and DD F, G, H (and larger) also exist. These biggest bra sizes are often needed by very large-breasted women, or women whose size increases with pregnancy and nursing. A training bra for developing girls (usually Tanner Stage 2, 3, or 4) is also available and is smaller than the A cup. This is sometimes called AA. (also known as Double D or sometimes called E). Though less common, the larger cup sizes of (double A) B 36 32 B C 38 D 42 C 34 32 AA 36 A 32A 30 AA D / F / G / H D / F / G / H D 40
  19. 19. The breasts grow further during pregnancy. This growth is much more uniform than that at adolescence. ANATOMY AND PHYSIOLOGY / BREAST / Development
  20. 20. ANATOMY AND PHYSIOLOGY / BREAST / Development Breasts sag if the ligaments become elongated, a natural process that can occur over time and by gravity (like the breast bouncing while exercising). ! The breasts revert to previous size with some sagging and stretch marks After pregnancy
  21. 21. To avoid the post-pregnancy effects on the breast, some women wears Pregnancy Support bras. This woman admits to wear Support bras during pregnancy. “ I wear Support bras almost 24 hrs. a day. I only remove it when taking the shower! - Sweet Life
  22. 22. The breasts of an aging woman diminish in size as the milk glands degrade. The breasts often become more saggy as this occurs and as the effects of gravity pull the breast tissue downwards. I. ANATOMY AND PHYSIOLOGY / BREAST / Development / Tanner’s Stage Because the breasts become less dense after menopause, it is often easier for radiologists to detect breast cancer on an older woman’s mammogram films, since abnormalities are not hidden by breast density. !
  23. 23. <ul><li>B. AXILLA, LYMPHATICS and BLOOD SUPPLY </li></ul><ul><li>a. Blood Supply: </li></ul><ul><ul><ul><li>Arterial – internal & lateral thoracic artery, thoracoacromial artery, posterior intercostal arteries </li></ul></ul></ul>ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System The internal thoracic artery arises from the subclavian artery near its origin. It travels downward on the inside of the ribcage, approximately a centimeter from the sides of the sternum, and thus medial to the nipple. It runs posterior to the internal intercostal muscles, but anterior to the transverse thoracic muscles. It continues downward until it divides into the musculophrenic artery and the superior epigastric artery around the sixth intercostal space.
  24. 24. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System Arteries carry oxygen rich blood from the heart to the chest wall and the breasts and veins take de-oxygenated blood back to the heart. The axillary artery extends from the armpit and supplies the outer half of the breast with blood; the internal mammary artery extends down from neck and supplies the inner portion of the breast.
  25. 25. Venous – axillary vein, internal thoracic vein, intercostal veins ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System
  26. 26. <ul><li>b. Lymph system - cleansing system for cellular waste in the body. It picks up leaked fluid, disposes of debris in the lymphatic stream and houses white blood cells involved in immunity. </li></ul>ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System
  27. 27. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System They are thin channels similar to blood vessels; they do not carry blood but collect and carry tissue fluid which ultimately re-enters the blood stream. Debris moves through the balancing processes of various pressure gradients.
  28. 28. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System It is a one-way transport system that can get easily clogged because it doesn’t have a pumping system of its own but rather the lymph itself is contractile that could propel the fluid ahead or, as a resistance vessel which have valves tending to stop the lymph in its place.
  29. 29. <ul><li>c. Lymph systems: * </li></ul><ul><ul><li>Pectoral nodes </li></ul></ul><ul><li>- Anterior, along the border of the pectoralis major inside </li></ul><ul><li>the anterior axillary fold </li></ul><ul><li>- drains the anterior chest wall (upper half of the trunk) and </li></ul><ul><li>much of the breast. </li></ul><ul><ul><li>Subscapular nodes </li></ul></ul><ul><li>- Posterior nodes, along the lateral border of the scapula; </li></ul><ul><li>palpated deep in the posterior axillary fold </li></ul><ul><li>- drains posterior chest wall, axillary tail of the breast and </li></ul><ul><li>portion of the arm </li></ul><ul><ul><li>Brachial / Humeral nodes </li></ul></ul><ul><li>- Lateral nodes, located along the upper humerus </li></ul><ul><li>- drains most of the arm </li></ul><ul><ul><li>Midaxillary nodes </li></ul></ul><ul><li>- Central nodes, lie along the chest wall, high in the axilla, </li></ul><ul><li>midway between the anterior and posterior axillary folds, </li></ul><ul><li>most frequently palpable </li></ul><ul><li>- drains 3 other groups of lymph nodes which are seldom </li></ul><ul><li>palpable </li></ul>I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System
  30. 30. I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System *
  31. 31. I. ANATOMY AND PHYSIOLOGY / AXILLA, LYMPHATICS & BLOOD SUPPLY / Lymph System * The lymphatic drainage of the breasts and other organs is particularly relevant to oncology, specifically to the diagnosis and treatment of cancer. The lymphatic system, because of its physical proximity to many tissues of the body, is responsible for carrying cancerous cells between the various parts of the body in a process called metastasis. The intervening lymph nodes can trap the cancer cells. If they are not successful in destroying the cancer cells the nodes may become sites of secondary tumors. The cancer cells can also break away from a tumour and spread to other parts of the body through the lymph system.
  32. 32. CONTENTS <ul><li>HEALTH HISTORY </li></ul>II. HEALTH HISTORY A. Ask about reason for seeking care. B. Ask about personal and family medical history C. Ask about her current health
  33. 33. II. HEALTH HISTORY <ul><li>A. Ask about reason for seeking care. </li></ul><ul><li>*Breast pain </li></ul><ul><li>Nipple discharge </li></ul><ul><li>Nipple rash </li></ul><ul><li>Lumps </li></ul><ul><li>Masses </li></ul><ul><li>Other changes </li></ul>II. HEALTH HISTORY / REASON FOR SEEKING CARE II. HEALTH HISTORY / REASON FOR SEEKING CARE
  34. 34. <ul><li>Ask about personal and family medical history </li></ul><ul><li>Personal history </li></ul><ul><li>– benign breast disease with biopsy findings of atypical hyperplasia or lobular carcinoma in situ carry significantly increased risks </li></ul><ul><ul><ul><li>Breast lumps </li></ul></ul></ul><ul><ul><ul><li>Biopsy </li></ul></ul></ul><ul><ul><ul><li>*Breast surgery – enlargement or reduction </li></ul></ul></ul><ul><ul><ul><li>*Breast disease – breast cancer, fibroadenoma, fibrocystic disease </li></ul></ul></ul>II. HEALTH HISTORY / PERSONAL AND FAMILY MEDICAL HISTORY Capsular fibrosis Gynecomastia in males
  35. 35. II. HEALTH HISTORY / PERSONAL AND FAMILY MEDICAL HISTORY <ul><ul><ul><li>a.2. Periods and pregnancies </li></ul></ul></ul><ul><ul><ul><li>* Patient’s menstrual cycle </li></ul></ul></ul><ul><ul><ul><li>Date of last menstruation </li></ul></ul></ul><ul><ul><ul><li>Number of pregnancies and live </li></ul></ul></ul><ul><ul><ul><li> births </li></ul></ul></ul><ul><ul><ul><li>Patient age during pregnancies </li></ul></ul></ul><ul><ul><ul><li>Complications </li></ul></ul></ul><ul><ul><ul><li>Breastfeeding </li></ul></ul></ul><ul><ul><ul><li>b. *Family history </li></ul></ul></ul><ul><ul><li>Breast disorder </li></ul></ul><ul><ul><ul><li>Breast cancer </li></ul></ul></ul><ul><ul><ul><li>Other types of cancer </li></ul></ul></ul><ul><ul><ul><li>early menarche, late menopause, and 1 st live birth after age 35 or no pregnancy all raise the risk of breast cancer two or three-fold </li></ul></ul></ul>! <ul><ul><li>having </li></ul></ul><ul><ul><li>a close relative with breast cancer greatly increases the patient’s risk of having the disease </li></ul></ul>!
  36. 36. <ul><li>c. Breast Health Exams </li></ul><ul><ul><ul><ul><li>Breast Health Practices </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Self-breast exam </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mammography </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Clinical Breast Exam </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>*Frequency of Health Exams </li></ul></ul></ul></ul>II. HEALTH HISTORY / CURRENT HEALTH Women with a family history of or a genetic predisposition for breast cancer – as well as women who have a personal history of cancer – may need earlier or more frequent screening tests and examinations. !
  37. 37. <ul><li>Ask about her current health </li></ul><ul><li>Breast changes </li></ul><ul><ul><ul><ul><li>Description - pain, tenderness, discharge, rash </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Age- some parts of changes are a normal part of aging </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Time of occurrence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Underarm changes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>*Medications </li></ul></ul></ul></ul><ul><ul><ul><ul><li> Birth control pills – cause breast swelling and tenderness </li></ul></ul></ul></ul><ul><li> *Contraceptive patches </li></ul><ul><li> Vaginal ring with estrogen </li></ul><ul><ul><ul><ul><li>*Diet – caffeine, linked to fibrocystic disease of breasts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lifestyle – has a possible link to breast cancer </li></ul></ul></ul></ul><ul><li>Stress </li></ul><ul><li>*Smoking </li></ul><ul><li>*Alcohol drinking </li></ul>II. HEALTH HISTORY / CURRENT HEALTH If you smoke, you’re also inhaling arsenic, benzene, cadmium, hydrogen cyanide, lead, mercury, including 44 types of poison, of which 43 are proven cancer-causing substances. -Sun.Star Cebu ! An increase in breast size is a common side effect of use of contraceptive pill. !
  38. 38. III. ASSESSMENT <ul><li>III. ASSESSMENT </li></ul><ul><li>A. BREAST </li></ul><ul><li>INSPECT </li></ul><ul><li>PALPATE </li></ul><ul><li>B. AXILLAE </li></ul><ul><li>INSPECT </li></ul><ul><li>PALPATE </li></ul>CONTENTS

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